Oral-health-related quality of life in adolescents: umbrella review

Background To evaluate oral conditions, demographic and socioeconomic characteristics of oral health-related quality of life (OHRQoL) in adolescents. Methods Umbrella review, conducted according to the Preferred Reporting Items for Systematic Reviews and Meta Analyzes (PRISMA) checklist. The search strategy used a combination of words, applied in the electronic databases PubMed, WebScience, Embase, Lilacs, Scopus and Cochrane. Included publications until January 2022, without restrictions. Data collection took place with systematized practices and the eligibility criteria were studies focusing on OHRQoL; teenagers; adolescentes; present the term “systematic review” and/or “meta-analysis” in the title or abstract. The quality assessment followed the Assessment of Multiple Systematic Reviews (AMSTAR 2) and the adherence of the article to the PRISMA was verified. Results Three hundred sixty-two articles were identified, and 22 were included, published between 2009 and 2022. 21 Systematic reviews focused on the English language. Most studies showed heterogeneity in the methodological structuring process: 10 articles were considered of low and 10 critically low quality. Clinical conditions associated with worsening in quality of life were dental caries, malocclusion, dental trauma, toothache, edentulism, need for orthodontic treatment, irregular brushing, and periodontal disease. Socioeconomic factors related to housing, parental education, access to health care, absence of siblings and nuclear family influence OHRQoL. Completion of orthodontic treatment, health promotion programs, dental care and safe housing all have a positive impact. Conclusion Worse oral health status, older age, female sex and worse socioeconomic status were significantly associated with worse OHRQoL. Trial registration PROSPERO CRD4202129352.

and are not restricted to physical effects, but associate family, social, economic, psychological, spiritual and environmental issues, depending on the accumulated risk throughout life [4].
In this context, adolescence is a period of vulnerability and involves hormonal, behavioral and psychological changes.Studies indicate changes in eating habits and aesthetic perception [5,6].Adolescents have specific needs and concerns that can cause oral disease [6].In this age group Malocclusion gingivitis and periodontal disease are very common problems.Such as dental caries and DMFT [6][7][8].
The literature report worse oral health conditions impact school performance and socialization [5].Impact on oral health-related quality of life (OHRQoL) increases proportionally with the severity of oral diseases [9,10].Fluorosis and dental caries impact on self-perception [11][12][13].Pain and aesthetic problems are associated with the worst OHRQoL reports and greatest impact on social and emotional domains [13,14].Socioeconomic and behavioral factors are reported to be strong predictors for the impact on OHRQoL.Maternal education level, family income and social support can significantly influence the adolescent's self-perception [15].
However, other studies observed that adolescents do not benefit from health care and attention, when compared to children and adults [15,16].Health practices, stress mechanisms, need for treatment, resistance to dental consultations, fear and anxiety about dental care are possible factors that impact health-related quality of life in teenagers, but they are rarely reported in the literature [11,[17][18][19].
Systematic reviews carried out to observe the methodological quality of the studies, and thath encourage the realization of new, well-designed research on the subject [9,10].This because, many studies report general limitations in the papers included, which may compromise the quality of the evidence of the findings.Disagreements between authors on the method of evaluating predictive factors such as caries, frequency of dental visits and the outcome related to OHRQoL [9,20], and the allocation of children and adolescents in the same group/assessment method may suggest biased data [9].They also indicate the importance of using validated and tested socio-dental measures in different populations to analyze the impact on OHRQoL in adolescents [9,10].Untill now, only two instruments assess the impact of oral health on the oral health-related quality of life of adolescents between 11 and 18 years of age: the Caregiver Perceptions Questionnaire , and the Child Oral Impacts on Daily Performances (Child OIDP [2,19].
Therefore, the objective of this study is to review the literature who investigates the possible relationship of oral health conditions, demographic, socioeconomic and behavioral characteristics with OHRQoL in adolescents, through an umbrella systematic review.

Protocol and registration
For this umbrella systematic review the preferred reporting steps for systematic reviews and meta-analyses (PRISMA) [21] were followed, conducted in accordance with this checklist.A public search protocol was submitted to the International Prospective Registry of Systematic Reviews (PROSPERO) under registration number: CRD42021293528.

Selection criteria
For this research, the inclusion criteria was articles characterized as a systematic review, with or without metaanalysis, without restriction of year of publication and language, which address the correlation between oral health conditions and a possible impact on quality of life in adolescents, of both sexes, 10 to 19 years old.Age established according to World Health Organization standards.
Systematic reviews, which included within their sample composition, individuals in a condition of vulnerable health, as well as pregnant women, or those in a situation of confinement/incarceration and indigenous people was excluded.

Information sources, search protocol and search strategy
The search strategy involved the identification of keywords, which were used in the electronic databases, in order to identify all studies that address the relationship: oral condition and impact on quality of life of adolescents.
-The search strategy used for the Medline (PubMed) was:

((Adolescents [MeSH]) OR (teenagers) OR (adolescence)) AND ((oral health [MeSH]) OR (mouth diseases [MeSH]) OR (oral health determinants)) AND ((quality of life [MeSH]) OR (OHQoL) AND ((systematic review).
This strategy was adapted to different databases, in accordance with their algorithms.The search included sevem databases: Medline (via PubMed), Embase, Scopus, Web of Sciences, Lilacs, Scielo and Cochrane, as well as the consensus between the evaluators and the consultation with the expert.In a period of twho weeks.

Selection of studies and calibration of evaluators
The study selection process followed the PRISMA guidelines [21].The results obtained from the search performed in the five consulted databases (Medline, via PubMed), Embase, Scopus, Web of Sciences, Lilacs and Cochrane) were exported to the Endnote ™ X8.2 [22].A database was created to facilitate the management and verification of duplicate articles.
Three independent reviewers (IGMC; BNCF; GPM) were previously trained and calibrated about the inclusion/exclusion criteria for the analysis of studies, through a pilot inclusion/exclusion round, analyzing the title and abstract of the articles obtained in the Search from PubMed.The article were read in full, if they did not provide enough information in the abstract.In this process, there was 100% consensus among the evaluators (Kappa = 1,0 high agrement).
The phase I of data extraction selected all sistematic reviews obtained through an Excel ™ file.The document was filled with data: article title, author, year of publication, journal, specialty, systematic review study, presence of meta-analysis and population studied (age of adolescents).

Selection of studies and data extraction
In the pahse I the reviewers (IGMC; BNCF; GPM) independently identified potential references, based on the title and abstract.In phase II, the articles were reed in full and irrelevante studies were exclued based in previously established criteria.The reason for exclusion of each article was documented.
In the next round, the selected articles were submitted to AMSTAR 2, a checklist composed of 16 items, with the objective of evaluating systematic reviews.Three reviewers (IGMC; BNCF; GPM) independently extracted relevant information: author, article name, year of publication, journal, outcome, independent variables, questions regarding the introduction, eligibility criteria, characteristics of the selected studies, quality analysis, risk of bias, presence of limitations and meta-analysis [23][24][25].
Also, the included studies had their references list manually checked by all reviewers to ensure the inclusion of possible works relevant to this topic.
Any source of conflict, throughout this process, was discussed until a consensus was reached.In case of discrepancy, a fourth reviewer was called.In addition, the authors were contacted in situations where the full article could not be obtained, or for clarification of information.

Result
The search strategy found 362 articles.Only 22 systematic reviews were included, as shown in Fig. 1.
Oral conditions, characteristics of the selected studies and the OHRQoL measurement instruments can be found in the supplementary material of this article.
The Table 2, provides important characteristics of the selected studies.

Impact of malocclusion on OHRQoL
The studies who avaliate occlusal disorders, concluded that this pathology have a negative impact on OHRQoL in adolescents [9,19,[27][28][29][30].There are divergences related to the degree of severity of impact on OHQoL.The emotional and social domains obtained higher scores when compared to the functional domains.Aesthetics and satisfaction with appearance have the greatest impact on OHQoL [34].The studies evaluated incisal crowding, maxillary anterior irregularity ≥ 2 mm, and overjet ≥ 5 mm.
Two systematic reviews note that only cross-sectional studies were included, which cannot record causality [28,29].In addition, it was inferred that adolescents with malocclusion have a greater impact on OHRQoL when compared to children.Adolescents who had never received orthodontic treatment had a greater impact on quality of life compared to patients who had already completed treatment [34,40,[44][45][46].Lastly, the study ndicate that the degree of negative impact on OHRQoL is directly proportional to the need for orthodontic treatment and its consequent aesthetic impairment [34].

TDI and OHRQoL
The impact of dental trauma sequelae on OHRQoL in adolescents was observed in five systematic reviews [31][32][33][34][35].The studies [31][32][33][34][35] show that uncomplicated traumatic injuries do not have a negative impact on the OHRQoL of adolescents.The negative effect is greater when it involves pulp exposure or darkening of the dental element [32], and the age group from 11 to 14 years is the most affected [35].Adolescents report difficulty smiling, eating, socializing, presence of pain, difficulty in chewing [34].
Treatment of TDI reduces the negative impact on OHRQoL in adolescents, based on parental perception [33].Individuals with a fractured tooth, who do not receive treatment, have a four times greater risk of reporting an impact on OHRQoL when compared to the group without trauma [34].Negative self-perception remains after tooth restoration.

Dental caries, periodontal disease, toothache, dental erosion, agenesis, edentulism, bruxism, DTM and OHRQoL
The impact of dental caries on OHRQoL was addressed in five systematic reviews [9,26,34,36,37].Three articles report that the greater the severity of the carious lesion, the worse the impact on OHRQoL in adolescents [9,26,34].As well as individuals with severe periodontitis had      worse OHRQoL scores [9].The association between caries and periodontal disease was demonstrated in an sistematic review.And the operative treatment of caries lesions has a positive effect on OHRQoL, despite the low quality of evidence [9].Toothache, DMT and tooth loss have a high impact on OHRQoL in adolescentes [26].While dental erosion and bruxism have not been shown to impact the quality of life of adolescents [26].In contrast, tooth agenesis does not have enough scientific evidence to support a relationship between OHRQoL [41].

Impact of health determinants on OHRQoL
Only three systematic reviews assessed the impact of oral health determinants on OHRQoL [36,39,43].It was observed that health promotion programs have a positive effect on OHRQoL.The reduction of oral problems and increased satisfaction with oral health in the development of daily activities such as chewing, brushing, talking, smiling and sleeping are reported in studies [39].
Another finding demonstrated that having parents who can provide dental care and safe housing are positive predictors for OHRQoL.The systematic review reports factors that physical disability, visual impairment, mental disorders, poor diet and irregular brushing negatively impact OHRQoL.While the influence of religion and age on OHRQoL is unknown [36].
Socioeconomic factors related to the area of residence, satisfaction with oral health and dental care were shown to be directly proportional to the OHRQoL outcome [36].The parental socioeconomic factor and family environment also influenced OHRQoL [43].Adolescents from families with higher incomes and higher levels of maternal education have better OHRQoL scores [34].Being an only child, growing up in your nuclear family or family structure, household conditions, and number of people per household and maternal age are predictors of better OHRQoL [43].While parental occupation, marital status, and the family provider being the mother or direct caregiver were not factors capable of impacting OHRQoL [43].It is noteworthy that the parent's place of origin, place of study, deleterious habits in the family, resistance to dental care on the part of the mother and use of dental care services do not have strong evidence.

Discussion
Many systematic scientific reviews on this topic are found in the literatue, in the process of writing this article.However, it is essential to consider the methodological rigor of the studies in order to expand scientific knowledge.Thus, supporting decision-making and generating data for the implementation of health strategies and programs focused on specific and vulnerable populations.This is the first systematic umbrella review to provide an overview of factors that impact HRQoL in adolescentes between 10 and 19 years of age.The main findings show that dental caries, malocclusion [9,[26][27][28][29][30], TMD [9], dental trauma (TDI) [32,34,35], poor brushing [36], toothache [26], periodontal disease [34] and edentulism [9] negatively affect the quality of life of adolescents.The need for orthodontic treatment [26,34] and the completion of orthodontic treatment [40,[44][45][46] also influence behavior and self-perception related to oral health in adolescents.This can be explained by the changes in adolescence and the increase in aesthetic perception, involving social, behavioral and psychological factors [5].In addition, we can see that pain and aesthetics cause greater demand for dental care, causing financial expenses and impact on quality of life and parents tend to report the worst impact.
Another important finding is related to social determinants, such as demographic and socioeconomic factors.Being an only child, growing up in your nuclear family, housing area and security, level of maternal education, access to dental care and the performance of health promotion programs are directly proportional to OHRQoL in adolescents [36,39,43,47].This can be explained by the level of information and awareness, which favors similar behaviors.People with higher educational level tend to make better health choices.
As previous studies reported, low socioeconomic status, poor social support, negative oral health beliefs and lower levels of protective psychosocial factors were significantly associated with unhealthy behaviours and poor HRQoL in adolescentes [4].Moreover, this indicators can be used to identify the risk of impaired OHRQoL already at the beginning of adolescence [48].This systematic review observed that the place of origin of those responsible and use of services does not have sufficient scientific evidence.Parental occupation, marital status and the family provider being the mother or direct caregiver were not able to impact adolescents' self-perception on OHRQoL [43].
Perhaps, these findings can be explained by the adolescents' self-perception related to group acceptance and social support from the environment they live in.There are two theories that can explain the process: the psychosocial conceptual model and the lifetime risk accumulation model.Family or social groups tend to present the same health behaviors and this can have a negative or positive influence throughout life.The socio-environmental context and health choices throughout life can influence the development of diseases, including the socioeconomic level of the adult individual.
It should also be said that the subject's condition of life is determined by the position he occupies in space in relation to the type of power or capital obtained.Thus, economic capital (income), while it can generate specific risks such as occupational ones, symbolizes greater access to care and living conditions, allowing better coping with the illness process; cultural capital (level of education) allows access to knowledge about the risks of becoming ill and prevention; symbolic capital (prestige, personal/professional recognition) is related to the subjective dimension of people's satisfaction with life, making them more normative in their environment; and social capital (social cohesion) concerns a set of elements of social organization, such as mutual trust, solidarity and civic engagement, which facilitate the coordination and cooperation of collective actions to achieve mutual benefits.Therefore, it can be said that exposure to different risks depends on how the individual places himself in different fields, as well as the relationships resulting from this position.
Biological data such as skin color and age have no concrete evidence about this impact in the OHRQoL.These factors could establish a strong correlation between demographic and socioeconomic factors.In the literature, this relationship is conflicting [48,49].There is great heterogeneity in age-related data collection.There is no standardized assessment.The cognitive understanding of a 5-year-old child is different from that of a 12-year-old, so it would be impossible to apply the same instrument to both age groups simultaneously.Thus, the questions are adapted and validated for the age group according to the cognitive needs of each one.It should be noted that self-perception and children's cognitive health are considered age-dependent and the result of continuous cognitive, emotional, social and language development.Therefore, it is important to obtain information from the child's parents or guardians in order to obtain complete information, thus obtaining an effective questionnaire, that is, capable of measuring the impact of oral conditions on the quality of life related to the oral health of children.
Another important aspect is the method of evaluating the OHRQoL outcome.Different measurement instruments were found in the 22 systematic reviews included in this study, which makes data analysis and results interpretation difficult.In this context, a large number of instruments that assess the impact of oral conditions on oral health-related quality of life have been produced and validated worldwide, with the aim of providing greater accuracy to individual and collective assessments.These instruments have become fundamental to complement clinical measures, but there is little guidance for the proper selection of these instruments, since there are principles to be followed.
In addition, the selected articles investigated different independente variable.Same variable presented different methods of observation and evaluation.Statistical approaches were also different, including univariate and multivariate regression.Therefore, the heterogeneity in the process of producing evidence and in the methodology proposed by the studies is highlighted.Likewise, differences were observed in the sampling according to age and gender.Age, developmental level and gender influence and affect the well-being of young people [34,50].Even the sample size of the different studies included in the systematic reviews demonstrate methodological flaws and limitations, which can lead the reader to misinterpret the results.
AMSTAR 2 was the instrument used in the present study, with the objective of critically qualifying the reviews.The tool has a robust and adequate method for evaluating sistematic reviews [21,23,24] and was deprecated from the RoB 2 (Cochrane risk-of-bias tool), as it focuses its analysis criteria on the field of randomized trials [24].In addition, a trend towards the adoption of AMSTAR 2 as a methodological quality assessment tool was observed in the umbrella reviews published in the medical and dental field [35,[51][52][53][54].
Three initially selected systematic reviews were later excluded due to lack of information, as the corresponding author did not respond to our contact to provide the necessary information.This fact can also be pointed out as a limiting factor, since the purpose of the umbrella review is to analyze the totality of sistematic reviews relevant to a given topic.It is impossible to ignore the fact that these studies could add new evidence, corroborate or refute the results obtained.
Umbrella systematic reviews are a recent modality of study, with no established conduction protocols.It is prudent to infer that this is a compilation of the above information organized in a concise manner.The search strategy was judicious, however there is a scarcity of studies with high quality on quality of life related to oral health.Important aspects such as tooth loss, agenesis, bruxism, TMD are neglected and little studied, despite the complaints of patients in the clinical routine.
The inclusion of gray literature was considered and a simple search strategy was even run in Opengrey and Google Scholar databases.As a result, an exorbitant number of works was obtained that did not meet the inclusion criteria, such as: theses, reports, annals and critical reviews.So, it was decided not to include the gray literature, despite not knowing the real harm in obtaining new evidence.

Conclusion
This systematic umbrella review found that dental caries, malocclusion, temporomandibular disorders, dental trauma, poor brushing, toothache, periodontal disease, and edentulism vahe a negative impact on oral healthrelated quality of life.In addition, social determinants, such as demographic and socioeconomic factors, like being an only child, growing up in your nuclear family, housing area and security, level of parental education, access to dental care and the performance of health promotion programs are directly proportional to OHRQoL and self-perception in adolescentes.Important aspects like gender and skin color did not have their level of impact clarified.These findings are important to clarify what context can cause negative impact in adolescents daily lives.Armed with this knowledge, strategies and public policies focused on this age group, will be assertive.

Fig. 1
Fig. 1 Flowchart of the search and article selection process, adapted from PRISMA guidelines

Table 1
Assessment of systematic reviews using AMSTAR 2 checklist

Table 2
Characteristics of studies select